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The selection of surgical approach for patients suffering from acute thoracolumbar spinal trauma is presently imbued with great controversy. The surgical method chosen depends on the type of fracture, anatomic and biomechanical factors, and the habits and experience of the surgeon involved. Due to new techniques for the posterior approach and the use of internal fixators, the indications for the anterior approach must be reassessed. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. Additional indications are seen in patients with vertebral body fractures with complete comminution and dislocation, noncorrectable burst fractures, and late misalignments. After removal of vertebral body and intervertebral disc fragments, autogenous bone should preferably be used for interposition. Different plates can be used for instrumentation. While anterior plates most often offer complete stability for the thoracic spine and a dorsal plating in this region can turn out to be quite difficult, in the lumbar spine, especially with destruction of additional posterior structures, one must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators. So far, we have gained experience from treating 39 patients with anterior decompression and stabilization. One of 19 patients with Frankel Grades A and B and 50% of the remaining 20 patients had improved one Frankel grade. Only a few of the patients with incomplete neurologic symptoms had back pain. All except for one returned to work. According to radiologic examinations, the average loss of correction amounted to 7%.